Gastroenterology: A Field With Endless Career Opportunities for Physicians and Scientists

Abstract

Gastroenterology is an exciting and burgeoning field that provides an extraordinary number of career opportunities for physicians and scientists. The unique blend of intellectual and procedural-based clinical practice coupled with the excitement surrounding scientific discovery has made gastroenterology an extremely popular career option. Moreover, the financial compensation and security within the field is certainly not a deterrent. The first American Board of Internal Medicine certification in GI was in 1941 when only a total of 8 individuals certified in this subspecialty.1American Board of Internal MedicineABIM Exam Information and Statistics: 2010. ABIM, Philadelphia2010Google Scholar Growth has been steady with >4000 individuals certifying in GI per decade since the 1980s,1American Board of Internal MedicineABIM Exam Information and Statistics: 2010. ABIM, Philadelphia2010Google Scholar with approximately 14,000 practicing gastroenterologists in the US today. The number of internal medicine residents applying to GI fellowships has risen over the past 5 years with 585 applicants in 2007 and 627 in 2010, with a match rate ranging from 47% to 55%, respectively.2National Resident Matching ProgramResults and data: 2010 main residency Match. National Resident Matching Program, Washington, DC2010Google Scholar There has been a modest rise in the number of first-year fellows in GI training programs over the past decade with 352 in 2001 and 470 in 2010,2National Resident Matching ProgramResults and data: 2010 main residency Match. National Resident Matching Program, Washington, DC2010Google Scholar which poses some concern regarding the ability to meet the demands for gastroenterologists to care for our aging population in the future. The main reason for the limited growth in GI fellows has been the existing cap on the number of CMS-funded slots available for graduate medical education. The exponential growth of scientific discovery in the domains of pathophysiology, diagnosis, and therapy of gastrointestinal disorders has led to the realization that incremental specialization within our field is necessary. There has been an increase in the number of subspecialty tracks (interventional endoscopy, hepatology, transplant hepatology, motility disorders, and inflammatory bowel disease), within training programs and clinical practices in response to the need for targeted expertise in the field. In fact, it is precisely this level of subspecialization and dramatic growth in scientific discovery that has led the AGA Institute Future Trends Committee to recommend a paradigm shift in gastroenterology training, such that the demands/needs of the future can be met.3Wang T.C. Fleischer D.E. Kaufman P.N. et al.The best of times and the worst of times: sustaining the future of academic gastroenterology in the United States—report of a consensus conference conducted by the AGA Institute Future Trends Committee.Gastroenterology. 2008; 134: 597-616Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar Most would say that career selection must be driven by a host of factors, with passion for the field or discipline leading the list. Other key variables include the vision of the individual's professional destination, family priorities, economic factors, impact of mentors, and opportunities that become available over time. The career opportunities in GI are many, extending from the pursuit of an academic position to selection of 1 of several private practice models. In addition, opportunities in nontraditional venues such as industry, finance, hospital administration, law, medical media, and consulting exist.4Kim J.K. Non-clinical career opportunities for physician executives.Physician Exec. 2010; 36: 82-85PubMed Google Scholar It is clear that complexity and expansion of medicine and science coupled with the changing health care and economic environment have transformed the traditional career opportunities available. In addition, generational change over time has moved young practitioners away from focusing primarily on “the career” as has been the case for “baby boomers,” to seeking a profession with variety and balance, incorporating family and personal interests into the mix.5Bickel J. Brown A.J. Generation X: implications for faculty recruitment and development in academic health centers.Acad Med. 2005; 80: 205-210Crossref PubMed Scopus (226) Google Scholar Academic health centers play a vital role in our society and are essential to the well-being of our communities. Discovery of new knowledge applicable to health and disease, education of the next generation of physicians and scientists, and provision of care to the communities where they are located (and beyond) are the 3 missions of academic health centers. The career opportunities in academic gastroenterology are extensive. Scientific discovery has ushered an era of excitement and possibilities not witnessed in the past. Although academic jobs are less lucrative than private practice, they provide a level of autonomy, flexibility, and general satisfaction that is difficult to parallel. Despite all of the attributes surrounding academic careers, there has been steady concern with the relatively small number of individuals who seek this career path, both in the United States and abroad.6Dornan T. Recruitment to academic medicine.Med Educ. 2009; 43: 300-302Crossref PubMed Scopus (4) Google Scholar There has been particular concern with the paucity of individuals pursuing basic science investigation as a career.7Donowitz M. Germino G. Cominelli F. et al.The attrition of young physician-scientists: problems and potential solutions.Gastroenterology. 2007; 132: 477-480Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar Oxentenko et al8Oxentenko A.S. Pardi D.S. Schmoll J.A. et al.Factors predicting initial career choices in gastroenterology fellows.J Clin Gastroenterol. 2007; 41: 445-450Crossref PubMed Scopus (10) Google Scholar examined whether there were specific factors that lead GI fellows completing training at The Mayo Clinic over a 10-year span to select private practice or an academic career. In final analysis, it seems that several factors, including race, gender, military background, and interest in pursuing an advanced fellowship, may a play a role in choosing an academic position. More recently, Adler et al9Adler D.G. Hilden K. Wills J.C. et al.What drives US gastroenterology fellows to pursue academic vs. non-academic careers? Results of a national Survey.Am J Gastroenterol. 2010; 105: 1220-1223Crossref PubMed Scopus (19) Google Scholar performed a National survey of US gastroenterology fellows in an attempt to examine the factors that drive selection of an academic or private practice career. After analysis of 184 surveys (14% response rate), the authors made several observations. First, the perception that a nonacademic salary would better meet their financial needs led individuals to select a nonacademic job. Next, the authors observed several characteristics of the individuals surveyed that predisposed selection of an academic career. These included older age (>35 years), having previously attained a graduate degree (Master's or PhD), a desire to work fewer hours, and having an interest in advanced training. These individuals were also interested in performing research and publishing. Additional findings were that 60% of respondents would select academic over nonacademic jobs if salaries were equal and that debt as well as a positive mentoring relationship did not impact career selection. Others have postulated that physicians within academia would benefit from increased attention to ensuring that there is clear alignment between their “inner direction” and the meaning of the work they are pursuing. It is only in this manner that professional fulfillment and true job satisfaction can be achieved.10Lieff S.J. Perspective: the missing link in academic career planning and development: pursuit of meaningful and aligned work.Acad Med. 2009; 84: 1383-1388Crossref PubMed Scopus (45) Google Scholar Borges et al11Borges N.J. Navarro A.M. Grover A. et al.How, when and why do physicians choose careers in academic medicine? A literature review.Acad Med. 2010; 85: 680-686Crossref PubMed Scopus (150) Google Scholar performed a literature review to examine how, when, and why physicians select a career in academic medicine. Although definitive answers to their questions were not achieved, several observations were made. Personal and institutional values were important in making this decision; prior training in research, gender, role models, and mentors play a role in this process; loss of interest in academia during residency training years owing to their personal observations of an academic environment impacted negatively on their decision to pursue academia, and debt may have a negative influence on making this decision. O'Sullivan et al12O'Sullivan P.S. Niehaus B. Lockspeiser T.M. et al.Becoming an academic doctor: perceptions of scholarly careers.Med Educ. 2009; 43: 335-341Crossref PubMed Scopus (66) Google Scholar performed a qualitative, cross-sectional study of a cohort of students, residents, and faculty members at a research-intensive medical school in an attempt to understand what factors influenced these individuals to pursue academia. Five themes were identified as playing a positive role in selecting an academic career, including early exposure to research, mentors and role models, well-defined career pathways, interplay of personal and social factors, and career support for junior faculty. Based on these observations, the authors suggest that greater opportunities in research should be structured within undergraduate and graduate medical education to motivate young learners to pursue this career path. Moreover, support for junior faculty to build on their potential to be effective role models for young learners should be strongly considered. Over the years, careers within academia have moved away from the traditional model where the academician was viewed as a triple threat (clinician, educator, and investigator). The rapid evolution of science and the complexity of clinical practice have led in turn to the development of career paths that are more focused on each one of the traditional missions of an academic health care center. Many institutions utilize tenure and nontenure tracks as the career foundation, with each track populated by individuals that focus on research, patient care, and education to varying degrees. Within each track, there are professorial ranks that include instructor/lecturer, assistant professor, associate professor, and professor. There are also institutions, like the University of California system, that have a greater number of tracks, each specifically designed to meet the needs of the academic environment. Ultimately, one must be familiar with the local options and must clearly understand the goals and expectations for each of the career paths. Moreover, the meaning of tenure varies from institution to institution; paying close attention to these factors is key when selecting a faculty position. Although not identical to other institutions, the faculty tracks at the University of Michigan bear general similarities to those found in several other academic centers. Therefore, I briefly review them herein as an illustrative example of an academic career pathway. In the instructional or tenure track, the expectation is that faculty devotes the majority of their time to biomedical investigation, be it basic science, clinical, or translational in nature. Early on, protected time performing research is essential, and time devoted to this endeavor should be in the 75%–80% range. Protected time for clinical investigators is also critical, but 50% protection is reasonable given that much of the research carried out by clinical investigators involves patients they see in their clinical practice. Promotion through the ranks and achievement of tenure depends on success in achieving independent funding, steady publications in peer-reviewed journals, excellence in service, teaching, and national (for assistant to associate professor promotions) and international (for associate to professor promotions) recognition. Achievement of tenure is time sensitive and may vary from institution to institution, with 7 years being a typical period within which tenure must be achieved, although some institutions have a 10-year tenure clock. Therefore, the benchmarks for being promoted and reaching tenure are institution dependent and the office of faculty affairs for the specific department clearly articulate and make readily available their guidelines. There is a nontenure research track, with 2 pathways—the research professor track and the research scientist track; the former includes an expectation for faculty to teach in addition to performing biomedical investigation. The most recent nontenure track developed at the University of Michigan, which also exists in many peer institutions across the country, is the clinical track. The clinical track was designed for individuals whose career focus is primarily in the domains of clinical care and education with less emphasis on organizational service and scholarship. A mandate for promotion through the ranks does not exist in this track, although it is a desirable expectation by the institutional leadership. Promotion is dependent on providing evidence of scholarship (publications, national and international presentations, etc) and organizational service. It is important to note that the requirements regarding number and type of publications needed for promotion are more flexible than those required on the instructional track, although again, there are variations across institutions. It is clear that there is a growing trend, although not mandated, for individuals to build formal graduate training into their portfolio as a way of enhancing the potential for a successful career in the chosen field. This is particularly true for individuals interested in clinical investigation and medical education. The process to navigate the pathway to successful promotion and tenure within an academic medical center will be the subject of future articles in this section of GASTROENTEROLOGY. Private practice opportunities continue to attract the greatest number of fellowship graduates, with approximately 85% of current gastroenterologists practicing within a private environment. Scientific advancement, changing rules for reimbursement associated with increasing economic pressures surrounding health care coupled with heightened specialization, and an invigorated process of quality improvement have been steadily changing the paradigm of clinical practice as we have traditionally known it. National organizations predict shortages in the physician workforce. Specifically, the mean age of practicing gastroenterologists is 54–55 years, consistent with steady attrition as existing practitioners retire. Finally, the shifting priorities of more recent generations, wanting to move toward more balanced lives, have led to a rise in young practitioners seeking alternative models of practice such as part-time opportunities with a greater level of job diversity. Practices have increased diversity in clinical practice by developing centers of excellence within areas of gastroenterology, such as inflammatory bowel disease and motility disorders. The financial pressures of running a practice and potential for economy of scale when investing in new and necessary initiatives such as an electronic medical record, have led practices to consolidate, moving away from the smaller group model to larger, standalone groups. Of current gastroenterologists in private practice, 60%–70% are in either large consolidated specialty groups or hospital/health care organization–owned multispecialty groups. Approximately 45% of current practitioners are within a multispecialty group practice and 55% are within independent single specialty groups (although detailed data are needed, these numbers are based on general estimates from leaders in the field; John I. Allen, personal communication). In the former, approximately 60% of individuals are based in a physician- or hospital-run organization with the remaining physicians working within an independent, multispecialty group. Although the traditional trend had been for gastroenterologists to choose small practices (1–3 members), the current trend is for individuals to select or move to larger, single-specialty practices (16–75 members). Larger groups provide flexibility, expanded breadth of care, and ease in coverage of a clinical service, as well as enhanced financial security. Survey data point toward higher salaries and greater predictability of time management as major reasons why individuals prefer a private practice setting. Characteristics of the private practice job that are less attractive include the time-intense schedule, the need for steady productivity, and the concern for burnout. Practices are addressing these negative issues by looking to provide more flexible schedules and increasing the emphasis on focused involvement in narrower areas of expertise within the field. The greatest challenges ahead for practice settings include the unknown impact that health care reform will bring including the introduction of accountable care organizations, changes in reimbursement models, and the overall reliance that the field has had over the last decade on the performance of screening colonoscopy. The later issue needs to be met with development of innovative models of care where expertise in fields such as obesity, cancer, and imaging are developed to meet the demands of the future. Individuals with a PhD have a broad range of career opportunities in gastroenterology. In addition to being recruited into a clinical or basic science department as a tenure-bound investigator or as a research scientist, opportunities in industry, education, law, and media and communications exist. Approximately 50% of individuals pursuing a PhD do so with the intent of entering an alternative career such as industry, education, policy development and communication (K. Barrett, personal communication). As with their MD counterparts, funding uncertainties, particularly given the current US National Institutes of Health climate, coupled with the complexity of academic life and the salary differential make industry a more appealing career choice for some. In addition, a career in industry provides the opportunity to be part of the application side of scientific discovery, through development of new drugs or diagnostic tools. Finally, there is a limit to the number of traditional research positions available, even within industry; thus, the realization that the training paradigm for PhD students needs to expand to incorporate some of the tools required to be successful in other domains within academia and industry including management, marketing, quality assurance, production, strategy, intellectual property, and regulatory affairs.13Schuster S.M. Commentary: attitude adjustment: educating PhD scientist for business careers.Biochem Mol Biol Educ. 2011; 39: 61-62Crossref PubMed Scopus (9) Google Scholar There has also been recognition that PhDs need specialized training if they are to pursue alternative careers in education. For example, in 1998 the National Institute of General Medical Sciences initiated the Institutional Research and Academic Career Development Awards. The primary goal of this innovative program is to facilitate the development of postdoctoral candidates toward research and teaching careers in academia. The program combines development of teaching skills with traditional mentored postdoctoral research experience through active partnership with a minority serving institution. There are also innovative PhD program in which additional training through an MBA or participation in a media fellows program can be pursued. Gastroenterology is an exciting and expansive field that provides a large menu of career opportunities for physicians and scientists. Biomedical discovery coupled with social and political change are transforming the career options available into ones in which the needs of our society and practitioners are being met. Passion should be the guiding force behind the decision of choosing a career coupled with thoughtful guidance by mentors and advisors. A clear understanding of the expectations to be met within one's selected organization, be it private or academic, is essential for success in any career path chosen. The author thanks John I. Allen for his input regarding private practice opportunities and Kim E. Barrett for her perspective on career options for PhD graduates.